Provider Demographics
NPI:1194714303
Name:BRENNEKE, STEPHEN LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LOUIS
Last Name:BRENNEKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5745
Mailing Address - Country:US
Mailing Address - Phone:503-766-3545
Mailing Address - Fax:503-342-3766
Practice Address - Street 1:10121 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5745
Practice Address - Country:US
Practice Address - Phone:503-766-3545
Practice Address - Fax:503-342-3766
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11314207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112187OtherMEDICARE GROUP
OR112188Medicare ID - Type Unspecified
OR112187OtherMEDICARE GROUP